Failure to Implement Enhanced Barrier Precautions and Maintain Infection Control Program
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during urinary catheter care for two residents with indwelling catheters. In one instance, staff provided catheter care and peri-hygiene to a resident with severe cognitive impairment, multiple comorbidities, and a suprapubic catheter, but did not use a barrier gown as required by EBP protocols. In another case, a staff member assisted a resident with an indwelling catheter and removed the urine collection bag without wearing gloves, also failing to follow EBP guidelines. Administrative staff confirmed that EBP should have been used during these care activities and that EBP should be included in the care plans. Additionally, the facility lacked a structured and documented infection prevention and control program. There was no documentation of infection tracking, including the type of infection, antibiotic usage, resolution, or additional cultures, for a period spanning nearly a year. Administrative staff acknowledged that infection tracking had not been performed for several months due to staffing changes and other priorities, and prior documentation could not be located. The facility's infection control policy outlined requirements for surveillance, reporting, and prevention, but these procedures were not being followed in practice. The deficiencies were observed through direct observation of care, interviews with staff, and review of medical records and facility policies. The lack of adherence to EBP during high-contact care and the absence of infection surveillance and documentation contributed to the facility's failure to maintain an effective infection prevention and control program as required by federal standards.